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Oldfield LE, Jones V, Gill B, Kodous N, Fazelzad R, Rodin D, Sandhu H, Umakanthan B, Papadakos J, Giuliani ME. Synthesis of Existent Oncology Curricula for Primary Care Providers: A Scoping Review With a Global Equity Lens. JCO Glob Oncol 2023; 9:e2200298. [PMID: 37141562 DOI: 10.1200/go.22.00298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
PURPOSE Global increases in cancer, coupled with a shortage of cancer specialists, has led to an increasing role for primary care providers (PCP) in cancer care. This review aimed to examine all extant cancer curricula for PCPs and to analyze the motivations for curriculum development. METHODS A comprehensive literature search was conducted from inception to October 13, 2021, with no language restrictions. The initial search yielded 11,162 articles and 10,902 articles underwent title and abstract review. After full-text review, 139 articles were included. Numeric and thematic analyses were conducted and education programs were evaluated using Bloom's taxonomy. RESULTS Most curricula were developed in high-income countries (HICs), with 58% in the United States. Cancer-specific curricula focused on HIC priority cancers, such as skin/melanoma, and did not represent the global cancer burden. Most (80%) curricula were developed for staff physicians and 73% focused on cancer screening. More than half (57%) of programs were delivered in person, with a shift toward online delivery over time. Less than half (46%) of programs were codeveloped with PCPs and 34% did not involve PCPs in the program design and development. Curricula were primarily developed to improve cancer knowledge, and 72 studies assessed multiple outcome measures. No studies included the top two levels of Bloom's taxonomy of learning (evaluating; creating). CONCLUSION To our knowledge, this is the first review to assess the current state of cancer curricula for PCPs with a global focus. This review shows that extant curricula are primarily developed in HICs, do not represent the global cancer burden, and focus on cancer screening. This review lays a foundation to advance the cocreation of curricula that are aligned to the global cancer burden.
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Affiliation(s)
| | - Vivien Jones
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Bhajan Gill
- Cancer Education, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Nardeen Kodous
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Rouhi Fazelzad
- Library and Information Services, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Danielle Rodin
- Royal College of Surgeons in Ireland, Dublin, Ireland
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Ben Umakanthan
- Cancer Education, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Janet Papadakos
- Cancer Education, Princess Margaret Cancer Centre, Toronto, ON, Canada
- The Institute for Education Research, University Health Network, Toronto, ON, Canada
| | - Meredith Elana Giuliani
- Cancer Education, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
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Saab MM, McCarthy M, O'Driscoll M, Sahm LJ, Leahy-Warren P, Noonan B, FitzGerald S, O'Malley M, Lyons N, Burns HE, Kennedy U, Lyng Á, Hegarty J. A systematic review of interventions to recognise, refer and diagnose patients with lung cancer symptoms. NPJ Prim Care Respir Med 2022; 32:42. [PMID: 36258020 PMCID: PMC9579201 DOI: 10.1038/s41533-022-00312-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 10/06/2022] [Indexed: 12/24/2022] Open
Abstract
Patients with lung cancer (LC) often experience delay between symptom onset and treatment. Primary healthcare professionals (HCPs) can help facilitate early diagnosis of LC through recognising early signs and symptoms and making appropriate referrals. This systematic review describes the effect of interventions aimed at helping HCPs recognise and refer individuals with symptoms suggestive of LC. Seven studies were synthesised narratively. Outcomes were categorised into: Diagnostic intervals; referral and diagnosis patterns; stage distribution at diagnosis; and time interval from diagnosis to treatment. Rapid access pathways and continuing medical education for general practitioners can help reduce LC diagnostic and treatment delay. Awareness campaigns and HCP education can help inform primary HCPs about referral pathways. However, campaigns did not significantly impact LC referral rates or reduce diagnostic intervals. Disease outcomes, such as LC stage at diagnosis, recurrence, and survival were seldom measured. Review findings highlight the need for longitudinal, powered, and controlled studies.
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Affiliation(s)
- Mohamad M Saab
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland.
| | - Megan McCarthy
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Michelle O'Driscoll
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Laura J Sahm
- School of Pharmacy, University College Cork, Cork, Ireland
| | - Patricia Leahy-Warren
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Brendan Noonan
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Serena FitzGerald
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Maria O'Malley
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
| | - Noreen Lyons
- Rapid Access Lung Clinic, Cork University Hospital, Cork, Ireland
| | - Heather E Burns
- National Cancer Control Programme, Health Services Executive, Dublin, Ireland
| | - Una Kennedy
- National Cancer Control Programme, Health Services Executive, Dublin, Ireland
| | - Áine Lyng
- National Cancer Control Programme, Health Services Executive, Dublin, Ireland
| | - Josephine Hegarty
- Catherine McCauley School of Nursing and Midwifery, University College Cork, Cork, Ireland
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Cook DA, Stephenson CR, Pankratz VS, Wilkinson JM, Maloney S, Prokop LJ, Foo J. Associations Between Physician Continuous Professional Development and Referral Patterns: A Systematic Review and Meta-Analysis. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:728-737. [PMID: 34985042 DOI: 10.1097/acm.0000000000004575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
PURPOSE Both overuse and underuse of clinician referrals can compromise high-value health care. The authors sought to systematically identify and synthesize published research examining associations between physician continuous professional development (CPD) and referral patterns. METHOD The authors searched MEDLINE, Embase, PsycInfo, and the Cochrane Database on April 23, 2020, for comparative studies evaluating CPD for practicing physicians and reporting physician referral outcomes. Two reviewers, working independently, screened all articles for inclusion. Two reviewers reviewed all included articles to extract information, including data on participants, educational interventions, study design, and outcomes (referral rate, intended direction of change, appropriateness of referral). Quantitative results were pooled using meta-analysis. RESULTS Of 3,338 articles screened, 31 were included. These studies enrolled at least 14,458 physicians and reported 381,165 referral events. Among studies comparing CPD with no intervention, 17 studies with intent to increase referrals had a pooled risk ratio of 1.91 (95% confidence interval: 1.50, 2.44; P < .001), and 7 studies with intent to decrease referrals had a pooled risk ratio of 0.68 (95% confidence interval: 0.55, 0.83; P < .001). Five studies did not indicate the intended direction of change. Subgroup analyses revealed similarly favorable effects for specific instructional approaches (including lectures, small groups, Internet-based instruction, and audit/feedback) and for activities of varying duration. Four studies reported head-to-head comparisons of alternate CPD approaches, revealing no clear superiority for any approach. Seven studies adjudicated the appropriateness of referral, and 9 studies counted referrals that were actually completed (versus merely requested). CONCLUSIONS Although between-study differences are large, CPD is associated with statistically significant changes in patient referral rates in the intended direction of impact. There are few head-to-head comparisons of alternate CPD interventions using referrals as outcomes.
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Affiliation(s)
- David A Cook
- D.A. Cook is professor of medicine and medical education, director, Section of Research and Data Analytics, School of Continuous Professional Development, and director of education science, Office of Applied Scholarship and Education Science, Mayo Clinic College of Medicine and Science, and consultant, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0003-2383-4633
| | - Christopher R Stephenson
- C.R. Stephenson is assistant professor of medicine, Mayo Clinic College of Medicine and Science, associate program director, Mayo-Rochester Internal Medicine Residency Program, and consultant, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0001-8537-392X
| | - V Shane Pankratz
- V.S. Pankratz is professor of internal medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico; ORCID: https://orcid.org/0000-0002-3742-040X
| | - John M Wilkinson
- J.M. Wilkinson is associate professor of family medicine, Mayo Clinic College of Medicine and Science, and consultant, Department of Family Medicine, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0003-1156-8577
| | - Stephen Maloney
- S. Maloney is professor of health professions education and deputy head of school, Primary and Allied Health Care, Monash University, Melbourne, Victoria, Australia; ORCID: https://orcid.org/0000-0003-2612-5162
| | - Larry J Prokop
- L.J. Prokop is a reference librarian, Plummer Library, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0002-7197-7260
| | - Jonathan Foo
- J. Foo is a lecturer, School of Primary and Allied Health Care, Monash University, Melbourne, Victoria, Australia; ORCID: https://orcid.org/0000-0003-4533-8307
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Gondhowiardjo S, Hartanto S, Wirawan S, Jayalie VF, Astiti IAP, Panigoro SS, Sekarutami SM, Rachman A, Bachtiar A. Treatment delay of cancer patients in Indonesia: a reflection from a national referral hospital. MEDICAL JOURNAL OF INDONESIA 2021. [DOI: 10.13181/mji.oa.204296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Cancer is a complex disease requiring a multidisciplinary approach in establishing prompt diagnosis and treatment. Treatment in a timely manner is crucial for the outcomes. Hence, this study aimed to provide information on treatment delay including patient and provider delays and its associated factors.
METHODS Cancer patients were recruited conveniently in the outpatient clinic of Department of Radiation Oncology, Cipto Mangunkusumo Hospital, Indonesia between May and August 2015. All patients were asked to fill a questionnaire and interviewed in this cross-sectional study. Treatment delay was explored and categorized into patient delay and provider delay. Patient delay could be happened before (patient-delay-1) or after (patient-delay-2) the patient was diagnosed with cancer. Provider delay could be due to physician, system-diagnosis, and system-treatment delays.
RESULTS Among 294 patients, 86% patient had treatment delay. Patient delay was observed in 153 patients, and 43% of them had a history of alternative treatment. An older age (p = 0.047), lower educational level (p = 0.047), and history of alternative treatment (p<0.001) were associated with patient delay. Meanwhile, 214 patients had provider delay, and 9%, 36%, and 80% of them experienced physician, system-diagnosis, and system-treatment delays, respectively. All types of provider delay were associated with patient delay (p<0.001).
CONCLUSIONS Most of the patient had treatment delay caused by either patient or provider.
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Koo MM, Unger-Saldaña K, Mwaka AD, Corbex M, Ginsburg O, Walter FM, Calanzani N, Moodley J, Rubin GP, Lyratzopoulos G. Conceptual Framework to Guide Early Diagnosis Programs for Symptomatic Cancer as Part of Global Cancer Control. JCO Glob Oncol 2021; 7:35-45. [PMID: 33405957 PMCID: PMC8081530 DOI: 10.1200/go.20.00310] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/06/2020] [Accepted: 11/06/2020] [Indexed: 12/15/2022] Open
Abstract
Diagnosing cancer earlier can enable timely treatment and optimize outcomes. Worldwide, national cancer control plans increasingly encompass early diagnosis programs for symptomatic patients, commonly comprising awareness campaigns to encourage prompt help-seeking for possible cancer symptoms and health system policies to support prompt diagnostic assessment and access to treatment. By their nature, early diagnosis programs involve complex public health interventions aiming to address unmet health needs by acting on patient, clinical, and system factors. However, there is uncertainty regarding how to optimize the design and evaluation of such interventions. We propose that decisions about early diagnosis programs should consider four interrelated components: first, the conduct of a needs assessment (based on cancer-site-specific statistics) to identify the cancers that may benefit most from early diagnosis in the target population; second, the consideration of symptom epidemiology to inform prioritization within an intervention; third, the identification of factors influencing prompt help-seeking at individual and system level to support the design and evaluation of interventions; and finally, the evaluation of factors influencing the health systems' capacity to promptly assess patients. This conceptual framework can be used by public health researchers and policy makers to identify the greatest evidence gaps and guide the design and evaluation of local early diagnosis programs as part of broader cancer control strategies.
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Affiliation(s)
- Minjoung Monica Koo
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, London, United Kingdom
| | - Karla Unger-Saldaña
- CONACYT (National Council of Science and Technology)–National Cancer Institute, Mexico City, Mexico
| | - Amos D. Mwaka
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Ophira Ginsburg
- Perlmutter Cancer Center and the Department of Population Health, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Fiona M. Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Natalia Calanzani
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Jennifer Moodley
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Cancer Research Initiative, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- SAMRC Gynaecology Cancer Research Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Greg P. Rubin
- Institute of Health and Society, Newcastle University, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, London, United Kingdom
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Druel V, Gimenez L, Paricaud K, Delord JP, Grosclaude P, Boussier N, Bugat MER. Improving communication between the general practitioner and the oncologist: a key role in coordinating care for patients suffering from cancer. BMC Cancer 2020; 20:495. [PMID: 32487036 PMCID: PMC7268533 DOI: 10.1186/s12885-020-06993-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 05/22/2020] [Indexed: 12/04/2022] Open
Abstract
Background Patients suffering from cancers are increasingly numerous in general practice consultations. The General Practitioner (GP) should be at the heart of the management of patients. Several studies have examined the perceptions of GPs confronted with the patient suffering from cancer and the relationships of GPs with oncologists, but few studies have focused on the patients’ perspective. We studied the three-way relationship between the oncologist, the GP, and the patient, from the patient’s point of view. Methods A questionnaire validated by a group consisting of GPs, oncologists, nurses, an epidemiologist and quality analyst, was administered over a three-week period to patients suffering from cancer receiving chemotherapy in a day hospital. Results The analysis was based on 403 questionnaires. Patients had confidence in the GP’s knowledge of oncology in 88% of cases; 49% consulted their GP for pain, 15% for cancer-related advice, and 44% in emergencies. Perceived good GP/oncologist communication led patients to turn increasingly to their GP for cancer-related consultations (RR = 1.14; p = 0.01) and gave patients confidence in the GP’s ability to manage cancer-related problems (RR = 1.30; p < 0.01). Mention by the oncologist of the GP’s role increased the consultations for complications (RR = 1.82; p < 0.01) as well as recourse to the GP in an emergency (RR = 1.35; p < 0.01). Conclusion Patients suffering from cancer considered that the GP was competent, but did not often consult their GP for cancer-related problems. There is a discrepancy between patients’ beliefs and their behaviour. When the oncologist spoke to patients of the GP’s role, patients had recourse to their GP more often. Systematically integrating a GP consultation to conclude cancer diagnosis disclosure, could improve management and care coordination.
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Affiliation(s)
- Vladimir Druel
- Department of Primary Care, University of Toulouse, 133 Route de Narbonne, 31062, Toulouse, France. .,Oncology Unit, Auch Hospital, Auch, France. .,Paul Sabatier University, Toulouse III, 133 Route de Narbonne, 31062, Toulouse, France.
| | - Laetitia Gimenez
- Department of Primary Care, University of Toulouse, 133 Route de Narbonne, 31062, Toulouse, France.,Paul Sabatier University, Toulouse III, 133 Route de Narbonne, 31062, Toulouse, France.,Inserm U1027, Faculty of Medicine, 37 allées Jules Guesde, 31073, Toulouse, France
| | - Kim Paricaud
- Department of Internal Medicine, Toulouse University Hospital, 29 Rue Emile Lecrivain, 31077, Toulouse, France
| | - Jean-Pierre Delord
- Paul Sabatier University, Toulouse III, 133 Route de Narbonne, 31062, Toulouse, France.,Institut Universitaire du Cancer de Toulouse-Oncopole, 1 Av. Irène Joliot-Curie, 31100, Toulouse, France
| | - Pascale Grosclaude
- Inserm U1027, Faculty of Medicine, 37 allées Jules Guesde, 31073, Toulouse, France.,Onco-occitanie, 1 Av. Irène Joliot-Curie, 31059, Toulouse, France
| | - Nathalie Boussier
- Department of Primary Care, University of Toulouse, 133 Route de Narbonne, 31062, Toulouse, France
| | - Marie-Eve Rougé Bugat
- Department of Primary Care, University of Toulouse, 133 Route de Narbonne, 31062, Toulouse, France.,Paul Sabatier University, Toulouse III, 133 Route de Narbonne, 31062, Toulouse, France.,Inserm U1027, Faculty of Medicine, 37 allées Jules Guesde, 31073, Toulouse, France.,Institut Universitaire du Cancer de Toulouse-Oncopole, 1 Av. Irène Joliot-Curie, 31100, Toulouse, France
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Weinmayr LM, Steinhäuser J, Gehring SC, Goetz K. Vaccination management for elderly patients in primary care settings - documentation and responsibilities during a vaccination campaign. Patient Prefer Adherence 2019; 13:1295-1302. [PMID: 31534316 PMCID: PMC6682325 DOI: 10.2147/ppa.s212507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/28/2019] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The aims of the current analysis were to evaluate the vaccination status and attitudes towards vaccinations of elderly patients and to explore effects of a vaccination campaign. METHODS The data were raised in primary care settings by a physicians network which collected data during routine care from 697 patients and by the analysis of health insurance claims data from the Kassenärztliche Vereinigung Schleswig-Holstein (KVSH/Association of Statutory Health Insurance Physicians of the federal state of Schleswig-Holstein, Germany), regarding vaccinations in the participating practices before and after a vaccination campaign. RESULTS Vaccination documentation for tetanus (57.7%), diphtheria (55.7%) and influenza (55.8%) was available for slightly more than half of the study sample. A lower documentation rate was observed for pertussis (33.1%), pneumococcal vaccination (30.3%) and polio (26.3%). Practice assistants were more responsible for determining the vaccination status than physicians. The attitude regarding influenza and pneumococcal vaccine was positive in 72.9% and 56.9% of patients respectively. After the campaign, rates of influenza and pneumococcal vaccine utilization increased by 13.4% and 62.9%, respectively. CONCLUSIONS Attitudes regarding vaccination were generally positive. Documentation was missing for almost half of the elderly population. The delegation of vaccine management to practice assistants could increase the immunization rate. Moreover, it can be assumed that a campaign might be helpful in increasing vaccination awareness and vaccine coverage.
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Affiliation(s)
- Lisa-Marie Weinmayr
- Institute of Family Medicine, University Hospital Schleswig-Holstein, Luebeck23538, Germany
| | - Jost Steinhäuser
- Institute of Family Medicine, University Hospital Schleswig-Holstein, Luebeck23538, Germany
| | - Svante Christoph Gehring
- Ärztegenossenschaft Nord eG, Bad Segeberg23795, Germany
- HANN Haus & Facharztnetz Nord GmbH, Norderstedt22851, Germany
| | - Katja Goetz
- Institute of Family Medicine, University Hospital Schleswig-Holstein, Luebeck23538, Germany
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Costa AMAM, Magluta C, Gomes Junior SC. Evaluation of continuing education of family health strategy teams for the early identification of suspected cases of cancer in children. BMC MEDICAL EDUCATION 2017; 17:155. [PMID: 28882154 PMCID: PMC5590150 DOI: 10.1186/s12909-017-0993-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 08/30/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND This study evaluated the influence of continuing education of family health strategy teams by the Ronald McDonald Institute program on the early diagnosis of cancer in children and adolescents. METHODS The study applied Habicht's model to evaluate the adequacy and plausibility of continuing education by using as outcome the number of children with suspected cancer who were referred to the hospital of references in the 1 year before and 1 year after intervention and the number of patients referred by intervention group and control group family health strategy teams. Medical records from each hospital of reference were used to collect information of suspect cases of cancer. Descriptive analyses were performed using frequencies and mean values. Chi-square tests were used to assess statistically significant differences between the groups and periods by using p-values < 0.05. RESULTS The results showed a 30.6% increase in the number of children referred to the hospital of reference for suspected cancer in the post-intervention period; in addition, the family health strategy teams that underwent the intervention referred 3.6 times more number of children to hospital of references than did the control group. Only the intervention group showed an increase in the number of confirmed cases. CONCLUSIONS This evaluation of a continuing education program for early identification of pediatric cancer showed that the program was adequate in achieving the established goals and that the results could be attributed to the program.
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Affiliation(s)
- Ana Maria Aranha Magalhaes Costa
- Unidade de Pesquisa Clínica, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz ( Fiocruz ), Av. Rui Barbosa 716 Flamengo, Rio de Janeiro, 22250-020 Rio de Janeiro Brazil
| | - Cynthia Magluta
- Unidade de Pesquisa Clínica, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz ( Fiocruz ), Av. Rui Barbosa 716 Flamengo, Rio de Janeiro, 22250-020 Rio de Janeiro Brazil
| | - Saint Clair Gomes Junior
- Unidade de Pesquisa Clínica, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz ( Fiocruz ), Av. Rui Barbosa 716 Flamengo, Rio de Janeiro, 22250-020 Rio de Janeiro Brazil
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